Pelvic/Supra-Pubic Pain

I. Problem/Condition.

Pelvic/supra-pubic pain has a wide and varied differential diagnosis. This differential is driven by the overlying structures (skin) as well as the internal organs that populate the pelvic and supra-pubic areas. It is important to understand the quality of the pain (constant versus colicky, dull versus sharp) and consider the time course over which the pain developed. Pelvic/supra-pubic pain results more acutely from trauma, infection, and perforation, while subacute and chronic pain results from inflammatory, lymphatic, and vascular complications. Careful consideration of these structures coupled with labs, imaging, and a thorough examination will allow the hospitalist to narrow a broad differential into a mature differential driven by evidence and pretest probabilities.

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

The most common diagnoses of pelvic/supra-pubic pain relate to uterine, gonadal, renal, and bladder complications. The other, less common causes of pelvic/supra-pubic pain, may include primary dermatologic and musculoskeletal problems as well as referred pain and neuropathies related to underlying vertebral and spinal cord complications. Specifically, the most common uterine diseases include pregnancy and dysmenorrhea. Ovarian and fallopian tubal complications include tubo-ovarian abscess, ovarian cyst, endometriosis, salpingitis, and ectopic pregnancy. Common renal causes of supra-pubic pain include pyelonephritis, perinephric abscess, and nephrolithiasis. Finally, uretral/bladder complications include infectious mechanisms of the genitourinary tract such as cystitis, urethritis, and prostatitis.

B. Describe a diagnostic approach/method to the patient with this problem.

Diagnosing pelvic/supra-pubic pain requires a thorough history, physical examination, and appropriate selection of labs and imaging.

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A thorough history, as detailed in the section below, is critical to define acuity of the pelvic/supra-pubic pain, as several surgical emergencies may present with it. By understanding the acuity, severity, and characterization of the pain, a targeted physical exam can be performed.

There are several approaches to generating a differential diagnosis list for pelvic/supra-pubic pain. One approach is to consider superficial or referred causes of pain, and then focus on peri-pubic causes of pain. Extra-peritoneal causes of pain include dermatologic diseases such as cellulitis, musculoskeletal causes such as pelvic bone fracture, neuropathies, and referred pain from the gonads in men. Intra-peritoneal and retroperitoneal causes relate to the organs that populate the pelvic/supra-pubic region which includes the ovaries, testicles, bladder, kidney, and uterus.

Once the physician creates a list of differential diagnoses, pre-test probabilities should be assigned to each diagnosis while also taking into account the acuity of diagnoses which cannot be missed. Finally, labs and evidence-based imaging can be ordered. Subspecialists, including Surgery, Urology, Gynecology, and Interventional Radiology, should be consulted if there is clinical suspicion that a procedure is warranted.

1. Historical information important in the diagnosis of this problem.

After considering the location of the pain and the systems involved, it is critical to get a detailed history from the patient that involves the following: frequency of pain, associated symptoms, radiation, characterizing the pain, time of onset, location of pain, duration of symptoms, exacerbating and relieving factors. These descriptors will dictate which organs are most likely to be involved. Key questions would highlight the following:

  • Colicky pain versus a constant pain would indicate a luminal obstruction. The most common lumen in this region include fallopian tubes (salpingitis), ureters/urethra (nephrolithiasis), and uterus (dysmenorrhea). Conversely, constant pain versus colicky pain would suggest disease of a solid organ (perinephric abscess, tubo-ovarian abscess, fibroids) or a lumen that has become obstructed.

  • Detailed sexual history. History of sexually transmitted diseases, type of contraception used, gender of sexual partners, dyspareunia.

  • Detailed obstetric and gynecologic history. Association of menstrual cycle with pain symptoms, duration and frequency of menstrual cycle, heavy/light flow, regular/irregular flow, amenorrhea.

  • Family history of diseases such as breast cancer, ovarian cancer, colon cancer, and polycystic kidney disease.

  • Urinary details. Dysuria, hematuria, fecaluria, increased frequency, incomplete voiding, decreases force of urinary stream, incontinence.

  • Systemic symptoms such as fever, chills, night sweats, weight loss, appetite changes.

  • Surgical history. Adhesions may be causing the pain or may represent another post-operative complication.

  • Recent trauma. Perforation of bowel, testicular torsion.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

The physical exam for a patient with pelvic/supra-pubic pain is in two parts: the first part of the exam consists of evaluating the supra-pubic region, including a basic abdominal exam which is described in another chapter. The second part is a genitourinary (GU) exam for either a man or woman.

When performing a supra-pubic exam, the patient must be draped in order to expose the suprapubic region, lying flat on the bed with his/her knees bent, and feet flat in order to relax his/her abdominal muscles. First, visually inspect the supra-pubic and lower abdominal area for trauma, lesions, bruises, veins, and surgical scars.

Second, auscultate the lower abdomen – listen for absence/presence of bowel sounds. Next, lightly palpate the lower abdomen and supra-pubic areas. If any masses are appreciated, proceed with a deeper palpation to characterize the size. If the patient exhibits any sign of rebound or involuntary guarding, this is highly concerning for an acute abdomen and surgery should be consulted immediately.

Palpating the kidneys is not always possible; however, you can assess if they are edematous or swollen by forming a fist and lightly tapping on the costoverterbral border on the left-side of the back. If costovertebral angle (CVA) tenderness is present, this may suggest pyelonephritis or perinephric abscess. Finally, percuss the lower abdomen; tympanic sounds indicate air in the bowel. A dull sounding abdomen is consistent with stool filled bowel, ascites, or an abdominal mass.

The GU exam for a woman consists of a speculum exam followed by a bimanual exam. When completing the speculum exam, the physician must pay attention to mucosal abnormalities, presence and characterization of vaginal secretion, and inspection of the cervix. Endocervical cultures should be obtained. During the bimanual exam, cervical motion tenderness and adnexal tenderness are most commonly associated with pelvic inflammatory disease (salpingitis, tubo-ovarian abscess). Presence of an adnexal mass may suggest ovarian torsion or tubo-ovarian abscess. The GU exam for men is addressed in a separate chapter.

Both men and women should undergo a rectal exam; a tender prostate indicates prostatitis in men; a bloody examination in women may indicated invasion of the intestinal lumen due to endometriosis.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Laboratory tests

  • Complete blood count (leukocytosis indicating infection, HELLP, ectopic pregnancy, Hbg/Hct -blood loss anemia)

  • Basic metabolic profile (renal insufficiency, BUN:creat ratio may suggest pre-renal versus renal versus post renal etiology)

  • Liver function tests (elevated protein gap may suggest hepatitis or HIV, HELLP)

  • Urinalysis and urine culture (nephrolithiasis, urinary tract infection – cystitis, urethritis, prostatitis)

  • HIV, acute hepatitis panel, RPR, HSV, syphilis – infectious causes of pelvic inflammatory disease, salpingitis, tubo-ovarian abscess, pyelonephritis, perinephric abscess

  • Nucleic acid amplification tests and/or endocervical cultures – GC/chlamydia in urine or from swabs (pelvic inflammatory disease, salpingitis, urethritis, cystitis)

  • Urine pregnancy test (pregnancy)

  • Serial hCG titers (ectopic pregnancy)

  • Type and screen (pregnancy, if transfusion needed)

  • Blood cultures (systemic spread of infection)

Imaging

Imaging is critical to characterizing the possible causes of pelvic/supra-pubic pain. Choosing the correct imaging modality based on your pretest probability is essential. The most important consideration for any woman of child bearing age is to first obtain a urine pregnancy test; a positive result will limit the imaging modalities available to the physician. Many of the imaging modalities related to gynecologic diagnoses are of limited value and often require more invasive methods to make a definitive diagnosis. The modalities and indications include the following:

  • Abdominal X-Ray – (bowel obstruction, nephrolithiasis – most types)

  • Abdominal ultrasound with Doppler imaging (nephrolithiasis, pyelonephritis with hydronephrosis, perinephric abscess, ovarian cyst/abscess, salpingitis, ectopic pregnancy (limited value)

  • Transvaginal/pelvic ultrasound (endometriosis, ectopic pregnancy >6 weeks, tubo-ovarian abscess, ovarian torsion)

  • Spiral computed tomography (CT) scan of abdomen – (nephrolithiasis)

  • Abdominal/ pelvic CT (perinephric abscess, pyelonephritis)

Other test: Testicular ultrasound with Doppler (testicular torsion) – discussed in corresponding chapter.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

Dysmenorrhea:

Sx: Menstrual pain with ovulatory cycles, wave-like cramping pelvic pain that may radiate to back or inner thigh, associated nausea and vomiting, headache, flushing

Labs: Urine pregnancy test

Imaging: Laparoscopy is often needed to differentiate endometriosis from pelvic inflammatory disease

Pregnancy:

Sx: Amenorrhea, nausea and vomiting, breast tenderness, urinary frequency and urgency

Labs: Urine pregnancy test, urinalysis, CBC, serologic testing for syphilis, rubella, varicella, Rh type, blood group, HIV screening, Hepatitis screening, cervical culture

Imaging: Fetal ultrasound as indicated

Pelvic inflammatory disease/Salpingitis/Tubo-ovarian abscess (spectrum of disease):

Sx: Uterine/adnexal/cervical motion tenderness, lower abdominal pain, low back pain, vaginal discharge, fever, rash, abnormal uterine bleeding, RUQ pain (perihepatitis)

Labs: Urine Pregnancy Test, Urinalysis, NAAT/Endocervical Culture for GC/CT, STD screening (HIV, syphilis), microscopy of vaginal secretions (> 15 wbcs)

Imaging: Transvaginal ultrasound, CT Abdomen/Pelvis

Ovarian cyst:

Sx: Nonspecific abdominal discomfort, bloating

Labs: Elevated CA125 in the presence of an abdominal mass

Imaging: Transvaginal ultrasound is useful in screening high risk women. Surgical evaluation should be performed if a malignant mass is suspected.

Ovarian torsion:

Sx: pelvic pain, nausea/vomiting, fever, abnormal genital tract bleeding, potential adnexal mass

Labs: pregnancy test (inc risk in pregnant women)

Imaging: Pelvic US with Doppler flow: decreased/absent flow can suggest torsion along with edema/hemorrhage of ovary. Surgical evaluation should be performed to preserve ovary.

Endometriosis:

Sx: Pelvic pain, dysmenorrhea, dyspareunia, rectal pain with bleeding (if bowel invasion)

Labs: CBC (blood loss anemia)

Imaging: Ultrasound is of limited value since cysts cannot be differentiated from neoplasm. Diagnosis is confirmed by laparoscopy

Ectopic pregnancy:

Sx: Amenorrhea, pelvic/adnexal pain that is sudden, sharp, and intermittent in nature, backache, shock in 10% of cases, vaginal bleeding/spotting

Labs: CBC (anemia), quantitative b-hCG/ml

Imaging: Transvaginal ultrasound (6 weeks from last menstruation cycle) – Lack of a gestational sac.

Laparoscopy is the confirmatory and therapeutic procedure

Cystitis:

Sx: Irritative voiding symptoms (frequency, urgency, dysuria), afebrile, pain with a full bladder

Labs: Urinalysis, Urine Culture, Blood culture, CBC with differential, Syphilis, HIV, Endocervical culture

Imaging: Abdominal Ultrasound or cystoscopy in men as it is rare and warrants workup

Urethritis:

Sx: Irritative voiding symptoms (frequency, urgency, dysuria)

Labs: Urinalysis, Urine Culture, CBC with differential, GC/CT NAAT, Syphilis, HIV, Endocervical culture

Imaging: None

Prostatitis:

Sx: Fever, lower urinary tract symptoms (hesitancy, increased frequency, decreased urination pressure), supra-pubic pain, tender prostate during rectal exam

Labs: Urinalysis, Urine culture, CBC with differential

Imaging: Abdominal Ultrasound (assess for urinary retention)

Pyelonephritis – symptoms usually persist for <5 days:

Sx: Dysuria, hematuria, flank pain, abdominal pain, fever, urinary urgency/frequency, nausea, vomiting

Labs: Leukocytosis with left shift, positive urinalysis (+ nitrites, + leukocyte esterase, WBC casts) and urine culture, blood cultures

Imaging: Abdominal CT with IV contrast (after 72 hours if failure to improve)

Perinephric abscess – symptoms usually persist >5 days:

Sx: Fever, flank pain, dysuria

Labs: Leukocytosis with left shift, positive urinalysis (+ nitrites, + leukocyte esterase, WBC casts) and urine culture, blood cultures

Imaging: Abdominal CT with IV contrast – modality of choice

Nephrolithiasis:

Sx: Colicky flank pain, nausea and vomiting, pain may refer to different areas as it progresses down the ureter, hematuria

Labs: Electrolyte abnormalities (Ca, Phos, uric acid), urinalysis (hematuria, pH)

Imaging: Abdominal CT w/ kidney stone protocol – modality of choice as it visualizes all stones except rare calculi due to indinavir

Abdominal X-ray – may diagnose most stones except uric acid or struvite

Renal Ultrasound with Doppler

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

Transvaginal ultrasound may not be tolerated or of limited use in certain patients. Thus, additional modalities such as transabdominal ultrasound, CT Scan, or MRI may yield more sensitive and specific results.

ESR and CRP are sensitive, but non-specific criteria used in the diagnosis of PID.

PSA – The evidence of PSA as a screening test is controversial. However, use of PSA along with a digital rectal exam is evidence-based per the American Urology Association.

CA125 – Not a useful screening test for ovarian cancer. However, it is useful when used in conjunction with an ultrasound in assessing postmenopausal women with ovarian cysts.

III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Pelvic/Supra-Pubic Pain.

Initial management of the patient consists of:

  • Airway protection (if indicated).

  • IV antibiotics (covering Gram negative rods including pseudomonas) if infection is suspected.

  • Early goal directed therapy with fluid resuscitation and cardiovascular stabilization.

  • All patients should remain NPO until clinical stability is determined and appetite returns.

  • Perform a urine pregnancy test immediately if patient is of child bearing age.

  • Assess if patient has an acute/surgical abdomen/pelvis. During the initial examination of the patient, the most emergent considerations are ectopic pregnancy, tubo-ovarian abscess, pyogenic nephrolithiasis, testicular torsion, atypical appendicitis, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, and acute abdomen secondary to another diagnosis such as perforated viscera.

  • Emergent imaging should include the most critical and likely diagnoses. Pelvic ultrasound is a cheap, easy test to perform that does not expose a potential fetus to radiation. Additionally, it is the preferred imaging modality when a gynecologic etiology is suspected. Abdominal and transvaginal ultrasound may help diagnose ectopic pregnancy, endometriosis, tubo-ovarian abscess, pelvic inflammatory disease, ovarian cysts, pyelonephritis, pyogenic nephrolithiasis, and perinephric abscess. However, additional imaging with CT, or more invasive procedures such as laparoscopy are often needed for a definitive diagnosis. CT is more useful when GI or urinary tract pathology is more likely.

  • Prompt Gynecologic consultation is also recommended in the Emergency Department if ectopic pregnancy is suspected. Additionally, Surgery or Urology consultation may be needed if the patient has an acute abdomen secondary to atypical appendicitis, perforated bowel, enteric fistulization, or testicular torsion. Interventional Radiologists may offer treatment options such as percutaneous drainage (perinephric abscess).

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

Immuno-compromised and elderly patients do not present typically for many of the diagnoses described above. Given their weakened immune system and their inability to mount a sufficient response to infection, the physician must always consider this when making a diagnosis.

IV Antibiotic choices for pelvic / supra-pubic pain must initially include broad coverage for gram positive (including MRSA), gram negative (double cover Pseudomonas if indicated), and anaerobic bacteria. Once a source is identified and speciated, the regimen can be further refined.

IV. What's the evidence?

Cates, W, Rolfs, RT, Aral, SO. “Sexually transmitted diseases, pelvic inflammatory disease, and infertility: an epidemiologic update”. Epidemiol Rev. vol. 12. 1990. pp. 199-220.

Donaldson, CK. “Acute Gynecologic Disorders”. Radiol Clin North Am. vol. 53. 2015 Nov. pp. 1293-307. (This is a review of studies looking at different imaging modalities in acute gynecologic disorders.)

Houry, D, Abbott, JT. “Ovarian torsion: a fifteen-year review”. Ann Emerg Med. vol. 38. 2001. pp. 156-159.

Greenberger, NJ, Blumberg, RS, Burakoff, R. “Current Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy”. 2012.

Knudson, MP. “Evaluation of acute abdominal pain in adults”. Am Fam Physician. vol. 77. 2008 Apr 1. pp. 971-8.

Longo, DL, Fauci, AS, Kasper, DL. “Harrison's Principles of Internal Medicine”. 2008.

McCormack, WM. “Pelvic inflammatory disease”. N Engl J Med. vol. 330. 1994. pp. 115-119.

McGee, S. “Evidence-based Physical Diagnosis”. 2007.

Tenore, JL. “Ectopic pregnancy”. Am Fam Physician. vol. 61. 2000. pp. 1080-1088.

Workowski, KA, Berman, SM. “Sexually transmitted diseases treatment guidelines, 2006”. MMWR Recomm Rep. vol. 55. 2006. pp. 1-94.

Sleisenger, MH, Feldman, M, Friedman, LS, Brandt, LJ. “Sleisenger & Fordtran's Gastrointestinal and liver disease: pathophysiology, diagnosis, management”. 2010.

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